Questions on Speech Therapy

Speech therapy podcast

A follow-up session to clarify the questions on speech therapy we received from parents.

Questions on Speech therapy

Question: What is the difference between a speech disorder and a language disorder?

A speech disorder is mostly where there is a difference in the way the information is conveyed; the ‘how’ aspect of speaking is speech disorder. So, there would be fluency-related issues where this flow is affected, like ‘I-I-I may t- t -t-talk like this.’ But what I speak, the content is not affected, and the way I deliver is affected. Or if I have some problem, like I’m not able to move my tongue, or I have a problem in my tongue, lips, or teeth, then it’s a speech disorder where, again, the content is not affected. But the way I deliver, the clarity, is affected.

Sometimes, even when we have a tooth removed or we have anesthesia for our tooth removal or some procedure, we know our speech is not very clear. Or when somebody has a voice problem, and you know they’re not able to talk. There’s a strained voice. Sometimes, when we have a cold or a lot of politicians or vendors and hawkers on the road, who keep using their voice a lot, even teachers, they have a voice-related concern. So, those are all speech disorders.

Language disorder is with respect to how the content is conveyed. There could be less number of vocabulary words. A three-year-old child who’s developing typically may talk in three-to-four-word utterances, but a child with a language disorder may talk like a one-year-old or a two-year-old. It could be due to multiple reasons, like a hearing loss or a vision-related issue, or he has a cognitive impairment from birth, where there’s intellectual disability or a processing-related issue like an autism spectrum disorder or an attention-related issue like we see an attention deficit hyperactive disorder. Or there could just be a delay because the child did not have enough people to talk to at home or was pampered too much that everything was given to the child before the child asked for them.

There’s no anticipation.

Exactly. Some children are not even left to crawl! They’re always carried, and they’re not left enough to explore, go around, and pull things, name it. And those are all language disorders.

Question: What are some common reasons that a child may show speech delays?

There could be a lot of reasons like one is sensory-related,  where they can’t hear or they are not able to see. We had an instance where a seven-year-old came, and she was not speaking adequately. She had some issues in copying, noting down dictation. But she responds when we call her name. Then later, we realized she has unilateral hearing loss. So, one ear alone was poor in picking up signals. The other one was good; it was compensatory and tended to get missed out. Sometimes, children have high-frequency hearing loss where only the high-frequency sounds are not heard clearly.

Or there could be other cognitive related issues. There could be some birth-related complications that would have led to some injury in the brain. Or any other reasons where there is an intellectual disability, the child’s cognition, or the IQ is low. That could be a reason why their child is talking late. Such children might have even started walking late. There could be neurological issues like cerebral palsy, where the child also has seizures. The child has other issues like the motor movement.

There could also be other conditions like learning-related issues where only when they go to school we will identify them. Till then, it will manifest only as a delay. The child may have some delay. They’re not talking like their peers. The child doesn’t reason out things and does not know the cause-and-effect relationship. All that is noted, but probably, we feel the child does not have enough exposure. Or, sometimes, we say, “We were a joint family earlier. We are nuclear now. That’s why the child is not having exposure.”

It’s not necessary that the nuclear family has to have less exposure. So, those could be misdiagnosed. And later, when the child goes to school, we see letter reversals are there. The child has issues with joining, putting words together, segmenting the words, and identifying sounds. Then we realize, oh, probably this is the reason why you had an issue earlier!

So, I remember seeing a child who was in fourth grade. He had gone for assessments, and they’d done the assessments, but the poor child had had multiple ear infections, and he wasn’t able to hear, but he had still done the assessments. So, when I asked the parents, they didn’t realize that they had to do something at that age to do something about the ear infection and the temporary hearing loss.

Temporary hearing loss, when left unattended, can lead to a permanent loss where the child is not going to hear, is totally dependent on the visual cues, the lip reading, and whatever the child sees. Often, we think it’ll be fine, and we think it’s okay to wait and watch. When we have a doubt, I would always suggest immediately get an assessment done. Wait and watch always doesn’t help because we miss the critical time, the early intervention phase, and then regret it later.

One of the other questions came to us: My 3-year-old pulls my hand and points to things he wants. He’s communicating because people in the family know what he wants. Should I wait for some more time before I start worrying?

If he is not using words, it’s advisable not to wait and start intervention. At least consult and get ideas on what can be incorporated at home. It’s good that he has an intent to communicate, that he’s trying to pull the hand. There are children who do not want. They will go take it themselves, or they’ll just be happy without anyone’s attention. But at least he is calling and pulling. In such scenarios, we always recommend ‘talk for the child.’ Be the voice for the child.

When he comes and points, say, “Mama biscuit. Mama go. Mama come,” when he comes and pulls. Whatever the child should say, you say it for the child so that way the child understands, “Oh, this is what I have to say here!” And it’s easy to just copy and tell, imitate. And then sometimes parents would say when he comes and pulls in an instance like that, sometimes parents will say, “You want me to come. You say “come” then I will come.” It’s an absolute “NO” recommendation from us.

Never do it. Never express that “I understood what you want, but you tell it verbally.” The child may ask for something, you know, water; they’ll say, “Oh, you want water?” They grab the bottle and say, “You say ‘water.’ I will give the water.”

That affects the child’s ego, and they also understand that “It’s understood. Why should I ask for it?” Some children just leave it and go, or they start crying. They start throwing tantrums, and 90% of the parents, when kids start throwing tantrums, end up giving in to calm the child. But then the child learns, “Okay if I don’t get it, I can throw tantrums and get it.” That becomes a habit over time and becomes difficult to break later.

You just talk for the child or give them choices, “You want water, or you want juice?” He points to something, or he takes the mother’s hand and points. “I want water.” You won’t say, “You want water.” Say, “I want water.” Whatever the child should say, the parent says it and gives it, and gradually focuses on getting it out of the child.

That is true! That withholding, and when the child cries, they give it, yes!

Yeah.

Question: So my four-year-old daughter has a lot of behavior problems. I was told to take her to a speech therapist because she’s not talking very much. What is the connection between talking and behavior?

Very much! Yeah, it’s very much linked. It goes back to the other question.

Think of our spouse or our parents; somebody takes us to a family member’s house whom we really don’t like. What do we do? We don’t talk much. We express our dislike towards objects, and we show it in a way where we cannot talk and tell. Sometimes, our teacher or somebody in a superior position gives us work or does something, and we are not able to talk back. We bang the door and go. We throw things! We throw the file! We express it in other ways.

Similarly, when children are not able to communicate and whatever they communicate is not understood by the parent, or whoever is talking to them, they show it through other ways. They have temper tantrums, they bang things, they throw things! The child might have indicated ‘I want idli today,’ but the parent would have made something else. So, she throws it. So the parent thinks, ‘No, the child is just throwing!’ They try to force feed, so it’s actually increasing the anger. Just imagine ourselves in that position.

When we are forced to do things we don’t like, we only know to throw things, cry, shout, and that’s what children do. We only need to sit back, think, and find out the reason. Every behavior has an antecedent. It is something that’s led to this, and a behavior from a child is only a consequence of what we are doing. If you identify that, then give them the choice or explain to them that this cannot be done now. Sometimes, you keep waiting for the child to talk verbally and force the child to do so. But there are other ways, there are multiple ways to communicate.

If a child is not talking, instead of just waiting, it’s good for parents and other family members to learn signs or consistent gestures. There has to be some way of expression. Not being able to communicate must be so frustrating for the child because the three-year-old wants to say so much. There’s so much they understand, and they want to get it out, but not being able to do that must be incredibly frustrating!

Exactly. And because they don’t express, we also underestimate their understanding capacity. We don’t know whether they know this. Many times, parents come and say, “Oh, I didn’t know he knows this!” Because the children are wonderful observers, and they would have observed a lot of things. They know much better, and when we give them a channel to communicate, they definitely do. It could be simple signs. It could be showing pictures. It could be showing actions. When we want water, we just show our hand. And when we wave bye, we don’t say bye; we wave! But sometimes, unfortunately, we think if we introduce other ways of communication, the child’s ability to speak may reduce. It’s definitely not that.

We all communicate through multi-modal ways. It’s important that we encourage that in children. There are some schools which or even daycare centers which introduce gestures to communicate, even at a very young age, like one and a half to two years. They teach them ‘more,’ they teach them ‘bye’ intentionally, consciously, these are taught. But unfortunately, when the child has a delay, we think we should restrict all of this. That’s again cutting down another channel. So, when we give a channel to communicate, the behavior automatically reduces – the undesirable ones. The child starts understanding, “Okay, I have a point to make, and my information or my behavior is acknowledged,” and the child feels they’re communicating more.

Question: How is a child’s play connected to speech and language development?

Play starts very young. We even keep telling parents to play, play, play! They ask us, you know, “How can I make my child start talking?” “Play! Forget everything and play!” So, children start developing play very young – when they start moving, when they start taking things and putting them into their mouths. A lot of cognitive, sensory, motor, and communication skills – are interlinked, and when children start taking objects, they put them into their mouth and start chewing. That’s an exploratory play.

Even for us, when we get our phone, the function of the phone is to call somebody. The moment we get a new phone, what do we do? We explore and try to find what are the functionalities. So, children do the same. When they get a toy, they explore, and when they do it, it means they’re on the right track. We try to control it, “No, no, no! Don’t play like this. This has to be played by these rules!” We should not be doing that. We let them explore first; the same thing with books or any objects. Explore! Exploratory play starts first.

Then, they do functional play, which is playing with the object the way it has to be. It could be the kitchen set, a doctor set, or a toy – a ball to throw and catch. That’s functional play, and gradually, they start manipulating the toys, moving, trying to see what parts will get removed and what all can be fixed, what makes a sound, and what has a different texture. All that happens, and then, when they start looking at other children play, they actually start looking at what they’re doing. How are they playing? They learn from each other.

Then comes parallel play. The child, one child plays, and another child plays next to each other. Slowly, there’s a cooperative play where they share things, and then they play together. They take turns. So, a lot of communication comes in. ‘I have to wait. I want this,’ When they start fighting…, all of us sort of experience at our home. There will be some toy which is untouched for years or months, and when another child comes and takes it, “Idhu Yennudhu! I want this. It’s mine! It’s mine!” So far, this child would have not even been talking. But where did this ‘It’s mine’ come from? So, there’s a lot of communication that happens with play.

And when we do role plays like, you know, kitchen set, doctor set, there is waiting for turns. One day, this child is a doctor. There another day, another child is a doctor. The same child gets into a patient role, and then, there’s this ‘theory of mind’, which we talk about a lot with autism spectrum disorder, where understanding other’s perspective is a challenge. So, this is when it comes into play when they do pretend play. They act out role plays, and they have to act like another person, so they have to change their voice accordingly. Their body language has to change. So, there’s so much of cognition, thinking, and effect that’s coming into play, and then they have to deliver it only through communication. So, there’s so much they learn. It’s not a fixed routine, but they modify it based on whom they’re playing with.And play is the best connect to another person.

When the adult plays with the child, the adult is adapting to the child, whereas when they’re playing with their peers, the child has to learn a completely different set of skills because it’s another child, not the adult, who’s anticipating their every move.

And there’s a lot of ‘win and lose’ when they do with a child. Sometimes, others give up, and they try to adjust to the child. But when it’s another child, they fight. And when they fight, we always suggest to parents, “When you have a play date, if there’s a fight, they want to escalate, they will escalate. You don’t go in barging.” There are times when parents brought in a video saying, “Wow! I had a play date with my child,” and then we saw the video – three mothers, three children, and they’re completely directing what the child has to do. “You take this, it’s your turn. You say like this!”

So, we say there should be some unstructured play. Let them play however they want. No rules! They set their own rules. Fifty percent of the time, at least, unstructured. Fifty percent, you would guide the way that you want because you want to facilitate communication in that. But fifty percent is at least unstructured. Do it the way they want.

Question: When children watch YouTube videos, they learn so many things. So why do experts tell us that we mustn’t give screen time to kids? Is there an age limit when kids can start watching TV?

Pre-COVID, there was a different way of telling. Post COVID, it’s all different because since COVID with lockdown children, everybody was exposed to long hours of screen. But having said that, the American Periodic Association, even the Indian Pediatric Association, all of them recommend zero screen time for less than two years. But sometimes it’s not really possible, especially when it’s a very small family. There’s nobody to take care. The mother has to go into the kitchen.

We give them ideas. We ask them for the routine and give them ideas on how they can reduce their screen time. We don’t tell them zero screen time because it’s practically not possible. And when we say zero, they will not listen to us at all. When we try to understand the situation at home, and we give them ideas, ‘Use it instead of this. Do this play. Reduce the half an hour to fifteen minutes. Reduce the six hours or seven hours to only during certain times. Do it after the child does this. Let it be like a reinforcement. The child finishes this activity. Then he can watch something.’

There are children who picked up a lot of vocabulary from YouTube videos they have picked up. I won’t deny that. There are six to seven-year-old children who come, and they don’t talk at all and they don’t have any sensory issues, no other issues, just because they were on-screen throughout the day. And it becomes more like an addiction that they have to see it.

Even now, parents slowly reduce it, but sometimes they do show it to them when they’re eating. They say that’s when he eats, or else he doesn’t eat at all. Then we say, at least of the three meals, at least two you do without it. One, we say one you do without the screen. Gradually make it to two. The child has to explore. It’s okay if he eats less, but he needs to feel the texture; he needs to know what he’s eating. A lot of overeating has happened because of screens, and they don’t know how much they’re eating. And they want to continue eating because they know the mother will show the screen till the child eats. After that, they’ll take it off.

When we go to restaurants now, if you see children are in front of the screen. So, what we also suggest is that, sometimes, what I do with my children is I take three, four toys in hand, and I don’t release everything at one go. So, once they get bored with something, then the other. The menu card is another one; they can just actually run through their fingers and look at it. There are many ways to engage, but parents are scared. And sometimes we just want to sit and relax because of the long day of, you know, taking care of the kitchen, cooking, washing… so much would be there. But some time off the screen is very important. Using it once in a while when I’m really tired, I’m unwell, I want my child to be occupied for some time…, that’s fine, but on a daily basis for long hours is definitely a no!

That’s a good point that you know about reducing the hours rather than saying absolutely no because you have to work with what they need.

Question: Children who are now school-age went through the COVID period during their critical language burst years. What have you observed in terms of their needs? Are our schools prepared to meet their needs?

Children who are in school now…, my younger son was born during COVID and the time that they were supposed to go around and explore was inside, indoor. And a lot of them had a screen and excessive screen time. That was the only way parents were able to occupy them. Some of them have developed a few words from that. Some have a significant delay without any associated issues, only a language delay because they were on screen for a longer time.

Again, there are some interesting facts we saw in those children. Their vocabulary has ‘mask’, which used to be a word that we learned very late. ‘Virus, mask, sanitizer,’ these are words that they actually understand. Also, their learning from digital media is very good. Some of the traditional schools where digital media is not really there, with complete board teaching, are definitely finding it hard to sustain their attention. Their attention span is very less, generally 25-30 minutes, and now they need something creative. They need something where they have to be participating than just listening to something.

I think, even with adults, our attention span has gone down. I’m personally not able to sit and listen to a webinar or attend a conference like I used to do pre-COVID. I think that restlessness, our attention has gone down and I think schools have realized…, I see some of the schools where there were no screens have put up screens in every classroom. There’s a digital platform where they can actually play music or show videos, show educational materials, which enhances teaching better. A one-hour class is easily transacted in seven to ten minutes of a video because everything is visually represented. The present generation, I think, are more visual learners. They understand that better.

Schools are understanding that there is a need to change, and they are working towards it. Even those schools that used to be very traditional and not supporting a lot of co-curricular activities, are focusing a lot on that – doing clubs, creative activities. Those are nice. That helps in skill development. I think they are going beyond books, lots of schools. It used to be a model that was considered a very Western model or a Montessori-based model, but now even general schools are taking up such activities. There are schools which have no book days; storytelling sessions are a part of everyday activities. So, I think schools are realizing and doing it.

One of the questions we got from a parent was, ‘My child has some speech problems. When we were overseas, she got therapy in her regular school, but here, we take her to therapy after school. Do you think our schools will start giving therapy?’

We see that there’s a trend that’s changing. A lot of schools are being sensitive about neurodiverse populations, and they are taking in children with special needs. Some schools are not really inclusive, but they are like any other child, and they take therapy outside. There are some schools where they have an inclusive setup. They have a special educator, an occupational therapist, and speech-language pathologists in-house who do a pull-out model. Depending on the child, the child is either pulled out 10% of the time, 20% of the time, or some only do after school hours, depending on their needs. There are in-house professionals.

On the other hand, parents want more therapy. In the evenings, the child is not occupied. For a child who does not have special needs, the choice that comes to the parent is an extracurricular activity, swimming, drawing, or dance. For a child with special needs, the evening is free. “Oh, let me look for some therapy for him!” instead of giving them an opportunity to learn another skill. We don’t need to bombard them with so much therapy. There should be at least one or two days free when the child can do something. It will depend on how accessible these coaching classes are. Are they okay to take your divergent children? So that will also have to be looked at.

That’s a good point. It can’t always be therapy -special ed, therapy – special ed. It has to be the fun…, other fun classes as well.

And they learn a lot from other children when they go and do these things.

Yeah. Yeah. Thank you very much, Doctor Krupa. Your podcast will be very beneficial for parents.

Read more here on the impact of COVID on language development:

How Covid-19 widened the language gap

Other podcasts in this series:

Speech, Language and Communication in the Early Years

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